| NPI | 1205296803 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 36043) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NJ 22DI02685300) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-02-25 |
| Last Update Date | 2024-07-23 |